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Health Center:

Pharmacy:

Capture Date :

To:

			Health Center	Pharmacy	ShipTo	Claim Type	RX Number	Member ID	Fill	Fill Date	Adjud Date	Captured Date	NDC	Drug Name	Strength	Form	Pkg Size	QTY Disp	Curr QTY	% of Claim	Status	Status Date	Order	Wholesaler Invoice
False	8552533		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000796001	MR00389011	00	02/11/2023	02/11/2023	02/12/2023	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	90	60	66.66700	Replenished		1002178117	3123055057
False	8464110		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795824	MR00018239	00	01/31/2023	01/31/2023	02/01/2023	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002178117	3123055057
False	8353471		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790352	MR00389011	08	01/19/2023	01/19/2023	01/20/2023	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002165418	3120576240
False	8353457		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000795570	MR00289972	00	01/19/2023	01/19/2023	01/20/2023	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002165418	3120576240
False	8090673		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790352	MR00389011	07	12/17/2022	12/17/2022	12/18/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002165418	3120576240
False	7860146		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790352	MR00389011	06	11/19/2022	11/19/2022	11/20/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002138200	3113250054
False	7695748		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793906	MR00018239	00	10/31/2022	10/31/2022	11/01/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	90	30	33.33300	Replenished		1002128006	3111198052
False	7698644		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000793906	MR00018239	00	10/31/2022	10/31/2022	11/01/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	90	60	66.66700	Replenished		1002138200	3113250054
False	7588081		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790352	MR00389011	05	10/17/2022	10/17/2022	10/18/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002128006	3111198052
False	7338530		Memorial Hospital	**Trapp Pharmacy (#1)	**Trapp Pharmacy (#1)	Third Party – Captured	000000790352	MR00389011	04	09/15/2022	09/15/2022	09/16/2022	00527329046	LEVOTHYROXINE 200 MCG TABLET	200 MCG	TABLET	90	30	30	100.00000	Replenished		1002128006	3111198052